Extra-Articular Tenodesis and Anterior Cruciate Ligament Reconstruction: Techniques and Outcomes

Introduction

Historically, anterior laxity in anterior cruciate ligament (ACL) deficient knees was treated surgically by isolated tenodesis, as described by Lemaire or MacIntosh. This procedure was largely abandoned in favor of single-bundle intra-articular ACL reconstruction, because although it effectively limited rotation of the tibial plateau relative to the femur, it only provided moderate control of anterior laxity. Since then, intra-articular ACL reconstruction has been the gold-standard surgical treatment for ACL tears. However, persistent rotatory laxity is a well-known complication of this surgical procedure and may be a cause of failure.

To improve control of rotational laxity, double-bundle ACL reconstruction was developed with an emphasis on independent reconstruction and tensioning of the posterolateral bundle of the ACL graft. This procedure is technically challenging and may not be an option in patients with small ACL footprints, but it has been shown to produce excellent results in the hands of experienced surgeons.

Another option to control excessive rotatory laxity is the addition of an extra-articular lateral tenodesis to a single-bundle intra-articular ACL reconstruction. Results of double-bundle ACL reconstruction and single-bundle reconstruction augmented with lateral extra-articular tenodesis seem to be comparable. The aims of this chapter are to review the clinical indications, surgical techniques, and reported results of augmentation of intra-articular ACL reconstruction with lateral extra-articular tenodesis.

The Anterolateral Ligament

Rotatory laxity in ACL deficient knees may be explained by the concept that anterolateral capsular injury is frequently associated with ACL tears. The capsular avulsion is termed a Segond fracture when associated with bony avulsion of the lateral tibial plateau, but does not always include an osseous fragment. Its presence is associated with increased rotational knee laxity. Rotatory laxity can also develop with time when chronic anterior laxity is left untreated, due to a progressive stretching of secondary restrains in the lateral aspect of the knee. Many recent anatomic and biomechanical studies have been published on this anterolateral capsular reinforcement, now widely called the anterolateral ligament (ALL).

In 2011 Vincent et al. performed a cadaveric and histologic study on the ALL and found that it was consistently present. It was described as a distinct fibrous structure that took origin just anterior to and blending with the popliteus tendon insertion on the femur. It inserted distally into the lateral meniscus and lateral tibial plateau 5 mm distal to the joint line and posterior to Gerdy’s tubercle. In 2013 Claes et al. published a cadaveric study on the presence and characteristics of the ALL in 41 unpaired, human cadaveric knees. They noted the ligament to be present as a well-defined ligamentous structure, clearly distinguishable from the anterolateral joint capsule in all but one of 41 cadaveric knees (97%).

In 2014 Van der Watt et al. published a systematic review on the structure and function of the ALL of the knee. Nineteen articles published between 1976 and 2014 were selected. This review identified the ALL to be a distinct ligamentous structure with a well-defined origin and insertion sites. It was found in 96% of knees examined. Published work by Sonnery-Cottet et al. has demonstrated that the ALL can be identified arthroscopically as well.

In 2015 Parsons et al. published biomechanical data on the ALL of 11 cadaveric knees. The contribution of the ALL to resistance of tibial internal rotation increased significantly with increasing flexion, whereas that of the ACL decreased significantly. At knee flexion angles greater than 30 degrees, the contribution of the ALL exceeded that of the ACL. In contrast, the ALL was not noted to contribute significantly to resistance of anterior tibial translation.

These anatomic and biomechanical studies confirm the existence of the ALL and support the concept of the addition of a lateral extra-articular tenodesis to the standard intra-articular ACL reconstruction in some patients with excessive rotatory knee laxity. Numerous techniques classically used for isolated lateral tenodesis have been modified and used as an adjunct to intra-articular ACL reconstruction in this manner. These combined procedures are advantageous for several reasons. First, the longer level arm of the lateral reconstruction allows for efficient control of tibial rotation. Second, the lateral tenodesis may effectively control rotational laxity, even in the face of failure of the intra-articular graft, provided a backup for the intra-articular graft in such cases. Finally, the addition of a lateral tenodesis may decrease the load seen by the associated intra-articular reconstruction. These advantages may be especially useful in cases of revision ACL reconstruction. One important contraindication to lateral extra-articular tenodesis is the presence of a posterolateral corner injury. In such cases, the tenodesis may tether the tibia in a posterolaterally subluxated position.

The Anterolateral Ligament

Rotatory laxity in ACL deficient knees may be explained by the concept that anterolateral capsular injury is frequently associated with ACL tears. The capsular avulsion is termed a Segond fracture when associated with bony avulsion of the lateral tibial plateau, but does not always include an osseous fragment. Its presence is associated with increased rotational knee laxity. Rotatory laxity can also develop with time when chronic anterior laxity is left untreated, due to a progressive stretching of secondary restrains in the lateral aspect of the knee. Many recent anatomic and biomechanical studies have been published on this anterolateral capsular reinforcement, now widely called the anterolateral ligament (ALL).

In 2011 Vincent et al. performed a cadaveric and histologic study on the ALL and found that it was consistently present. It was described as a distinct fibrous structure that took origin just anterior to and blending with the popliteus tendon insertion on the femur. It inserted distally into the lateral meniscus and lateral tibial plateau 5 mm distal to the joint line and posterior to Gerdy’s tubercle. In 2013 Claes et al. published a cadaveric study on the presence and characteristics of the ALL in 41 unpaired, human cadaveric knees. They noted the ligament to be present as a well-defined ligamentous structure, clearly distinguishable from the anterolateral joint capsule in all but one of 41 cadaveric knees (97%).

In 2014 Van der Watt et al. published a systematic review on the structure and function of the ALL of the knee. Nineteen articles published between 1976 and 2014 were selected. This review identified the ALL to be a distinct ligamentous structure with a well-defined origin and insertion sites. It was found in 96% of knees examined. Published work by Sonnery-Cottet et al. has demonstrated that the ALL can be identified arthroscopically as well.

In 2015 Parsons et al. published biomechanical data on the ALL of 11 cadaveric knees. The contribution of the ALL to resistance of tibial internal rotation increased significantly with increasing flexion, whereas that of the ACL decreased significantly. At knee flexion angles greater than 30 degrees, the contribution of the ALL exceeded that of the ACL. In contrast, the ALL was not noted to contribute significantly to resistance of anterior tibial translation.

These anatomic and biomechanical studies confirm the existence of the ALL and support the concept of the addition of a lateral extra-articular tenodesis to the standard intra-articular ACL reconstruction in some patients with excessive rotatory knee laxity. Numerous techniques classically used for isolated lateral tenodesis have been modified and used as an adjunct to intra-articular ACL reconstruction in this manner. These combined procedures are advantageous for several reasons. First, the longer level arm of the lateral reconstruction allows for efficient control of tibial rotation. Second, the lateral tenodesis may effectively control rotational laxity, even in the face of failure of the intra-articular graft, provided a backup for the intra-articular graft in such cases. Finally, the addition of a lateral tenodesis may decrease the load seen by the associated intra-articular reconstruction. These advantages may be especially useful in cases of revision ACL reconstruction. One important contraindication to lateral extra-articular tenodesis is the presence of a posterolateral corner injury. In such cases, the tenodesis may tether the tibia in a posterolaterally subluxated position.

Surgical Technique

Isolated Extra-Articular Tenodesis

Several techniques for isolated lateral extra-articular tenodesis have been described. The Lemaire procedure ( Fig. 140.1 ) was first described in 1967. This extra-articular tenodesis uses a strip of iliotibial band measuring 18 cm long and 1 cm wide that is left attached to Gerdy’s tubercle ( Fig. 140.2A and B ). Two osseous tunnels are prepared: one in the femur, just above the lateral epicondyle and proximal to the lateral collateral ligament (LCL) insertion (see Fig. 140.2C ); the other through Gerdy’s tubercle on the proximal lateral tibia (see Fig. 140.2D ). Then the graft is passed under the LCL, through the femoral bone tunnel, back under the LCL, and finally inserted into Gerdy’s tubercle via the bone tunnel (see Fig. 140.1 ). Graft fixation is done at 30 degrees of knee flexion, with neutral rotation. When this technique is performed in association with a standard ACL reconstruction, a technical problem can be encountered in the lateral distal femur when the femoral tunnel made for the ACL graft interferes with the femoral tunnel made to anchor the iliotibial band graft. The MacIntosh procedure is similar to the Lemaire procedure; however, femoral fixation is achieved not via a bone tunnel but rather through suture fixation to the lateral intermuscular septum.

Extra-Articular Tenodesis with Anterior Cruciate Ligament Reconstruction

In 1979 the Marshall-MacIntosh procedure (MacIntosh 3) was described, which utilized the central third of the entire extensor mechanism to perform both an intra- and extra-articular reconstruction. This same concept of performing a lateral extra-articular tenodesis associated with an intra-articular ACL reconstruction is frequently accomplished today using a variety of techniques.

Neyret et al. reported a technique based on three works, which has been described in detail by Magnussen et al. In this technique a patellar tendon autograft is used for an intra-articular reconstruction of the ACL, and a gracilis autograft is used for the extra-articular tenodesis ( Fig. 140.3A ). The gracilis is passed through the tibial bone block of the ACL graft (see Fig. 140.3B ). The ACL graft is introduced into the knee through the femoral tunnel, and the tibial bone block is impacted into the tunnel and press-fit, thus anchoring the femoral side of the extra-articular tenodesis (see Fig. 140.3C ). A tunnel is drilled in the Gerdy’s tubercle on the tibia. The two free ends of the gracilis graft are passed distally. The most posterior one is passed under the LCL (see Fig. 140.3D ), superficial to the popliteus tendon, and through the bony tunnel in Gerdy’s tubercle from posterior to anterior. The most anterior one is passed under the LCL, superficial to the popliteus tendon and under the posterior portion of the iliotibial band, and then through the same tunnel in Gerdy’s tubercle from anterior to posterior. Tensioning of the graft is done at 30 degrees of knee flexion and in neutral rotation. The two limbs of the graft are sutured to one another, side to side

Colombet described a navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graft. In this technique, the gracilis and semitendinosus (ST) tendons are harvested and, depending on their length, are prepared in the setting 4 + 2 (the intra-articular part of the graft is composed of four strands, two from the gracilis and two from the ST; the extra-articular part has only two strands) or 2 + 2 (the intra-articular part consists of two strands, one from the gracilis and one from the ST; the extra-articular part has two strands; Fig. 140.4A ). In both cases the intra-articular part of the graft is fixed in the femoral and tibial tunnels, and the extra-articular part of the graft is passed under the iliotibial band and fixed in a second tibial tunnel via an interference screw, with the tibia in neutral position (see Fig. 140.4B ).